Provider Demographics
NPI:1609210145
Name:IKEDA, KAZUMI (OTR/L)
Entity Type:Individual
Prefix:
First Name:KAZUMI
Middle Name:
Last Name:IKEDA
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12435 W JEFFERSON BLVD
Mailing Address - Street 2:APT 102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-6974
Mailing Address - Country:US
Mailing Address - Phone:510-798-4143
Mailing Address - Fax:
Practice Address - Street 1:1115 S SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3940
Practice Address - Country:US
Practice Address - Phone:626-962-4011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-27
Last Update Date:2013-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA664225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist